North Dublin GP Dr Finola Minihan was appointed by the Irish College of General Practitioners (ICGP) as national director of the CME small group learning network in March 2019. She works closely with Dr Stephanie Dowling, the recently appointed assistant national academic director of the scheme, and Dr Claire McNicholas, assistant programme director of CME.

The CME network is a considerable logistical operation. Says Finola: “Our latest figures show that last year we held 1,267 CME small group meetings across the country, with an average attendance of 9.8 GPs at each meeting. In total, there were 12,401 GP attendances. 

“The 38 tutors put in a lot of work in organising the meetings and in helping to run the scheme, while the thousands of GPs who attend each year are also making a big commitment, when you consider that GPs at the end of a day’s work are willing to go out to a meeting and spend two hours discussing a clinical topic.  It’s very gratifying to know that GPs – both those running CME and taking part in it – are willing to embrace this level of commitment, and this is what has helped make the small group learning network such a success story.

“Stephanie Dowling has recently carried out extensive research on the scheme, which has shown that GPs who attend small group CME meetings on a regular basis tend to have higher morale and lower stress levels than other GP groups. Emerging research also shows that there is a significant increase in the level of knowledge on a particular clinical topic by the end of a small group meeting, that this knowledge is sustained six months later and that it changes how people practise.” 

Finola believes this is a reflection of the strength of the CME scheme. “When you consider that its resourcing has been so restricted in the past decade or so, and that with the advent of PCS, the numbers of GPs attending have almost doubled, the scheme has really been punching above its weight.”

The small group learning network was the brainchild of Michael Boland (the first College chairperson and the College’s first Postgraduate Resource Centre director), who initiated and developed the scheme in its earlier days. This work was continued by his successor as national director, Annraoi Finnegan. 

“Michael”, says Finola, ”was a great forward thinker who was able to persuade the health authorities to fund the small group education model, which was a revolutionary concept back in the 1980s. Annraoi continued Michael’s good work and both of them are responsible for growing the CME network to what it is today. 

“I am supported in my role by Dr Tony Cox, ICGP medical director, and CEO, Fintan Foy and I attend at least one meeting of the senior management team in the College every month. This ensures CME remains at the forefront of the ICGP’s activity. They have both been very supportive to me and to the tutor network. From an administrative perspective I would also like to acknowledge the assistance of Carol White in Lincoln Place.”

CME a vital part of general practice

“CME has always been so important in my own working life. It’s a vital part of Irish general practice and it needs to be protected and strengthened to ensure that it remains so.”

A graduate of TCD, Finola did her GP training in Surrey and set up her own practice in Balbriggan in north county Dublin in 2016. She has always had a great interest in GP education. She is a trainer with the North Dublin scheme and has served as CME tutor with the Corrigan Faculty since 2015.

“When I moved back from England to practise in north Dublin I didn’t really know the local GPs. Luckily, I was able to join the local CME group and this made a huge difference. I quickly felt that I was becoming part of the local medical community. My first tutor was Ming Rawat, who was a tremendous educator for me and is now a good friend. She helped get me involved in GP training when she and Austin O’Carroll were setting up the north Dublin Inner City training scheme. I can link so many positive things in my professional life to my participation in the CME scheme. 

“The level of support CME gives to GPs is incalculable and it also gives us a great social outlet. It has played a huge role in ending isolation among GPs and in breaking down barriers between local practices.”

Finola says ensuring that CME is properly resourced is a major issue. “We recently had an increase in the number of tutors from 36 to 38, with the College funding the two additional posts. We have also been supported by the College in funding for the attendance of some tutors at the WONCA Europe meeting in Berlin this year. 

“Stephanie’s research will help in convincing the HSE of the real value of CME and the need for additional State resourcing. While College’s assistance with funding has been vital, it’s not feasible in the longer-term for the ICGP to be contributing to the costs.”

Both Finola and Stephanie are aware of the depth of knowledge that the clinical leads in the ICGP have in their various areas. Says Finola: “Recently, GP clinical lead, Joe Gallagher has been assisting us with an educational package for tutors on heart failure while Dermot Nolan has been working with us on asthma and Mark O’Kelly will be assisting us with a package on COPD. 

“One of the challenges that College has faced is how to integrate all of its various resources better. The changes in the administration of the CME network has led to the network and College working more closely together, and this is a positive for everybody.” 

Pressure to meet local CME needs

According to Finola, some faculties are under pressure to meet local CME needs. “In the past, CME tutors were looking after around three groups each, but with increased demand some are now supervising up to three times that number.”

In recent years, to cope with the demand for CME, more CME groups are being led by group leaders. 

“The tutor will give a topic to a group leader, who is a GP scheduled to attend the meeting and they will brief the group leader before the meetings. The group leader will take charge of the meeting, and give feedback to the tutor afterwards.  While this is important in terms of meeting the demand for CME, and the group leaders are very dedicated, they do not receive the structured national training in terms of facilitation skills and group management that the tutors would enjoy. I would hope to be able to roll out group leader training courses next year.

“Another priority is to increase the number of tutors, particularly in urban areas where there are some unmet demands for CME. Crucial to this of course, is to convince the HSE that it needs to provide additional funding for the CME scheme.”

Finola says with some CME groups, there are waiting lists for GPs who wish to join. “We plan to set up a centralised waiting list in College. People will be able to log onto their ICGP account and then request a place in a group in whichever area they live in that would be convenient to them. At present the average waiting times to get onto CME schemes vary. In my own area of north Dublin, the current waiting time is around 12 months – previously it was longer but we managed to reduce it after we got an additional tutor. We are working on reducing it further.” 

Finola Minihan: “The level of support CME gives to GPs is incalculable.”(click to enlarge)

The waiting lists are indicative of the pressures the CME scheme is under and this highlights the need for additional resourcing from the HSE, Finola says.

“A positive factor with the system is that you can get a good mix of establishing and older GPs, providing a blend of knowledge and experience. However, we need to provide easier access to small group learning for younger, recently qualified GPs.”

What happens at a CME meeting? Says Finola: They are usually held in hospital teaching rooms, in hotels, or HSE buildings, and some are held in GPs’ houses or practice centres. The meeting will be led by a CME tutor or group leader who will introduce the topic. There is usually dedicated time allocated whereby a GP might have a clinical question or conundrum and wants the group to discuss it and offer advice. The CME tutor or group leader will introduce the topic of the meeting. 

“Usually the topic is on how to manage common conditions such as heart failure or asthma, and new thinking or developments on management. The topic could also be a practical issue like polypharmacy, drug interactions, or deprescribing. Other topics explored could be death and caring for dying patients and how that affects the GP. In the coming year we have some material prepared on open disclosure, which is a hot topic.

“A lot of the time, case scenarios will be used to explore a particular subject. Some tutors like to use multiple choice questions as a way of exploring a topic.”

The real value of CME, Dr Minihan says, is that people talk about what they are doing every day in their practice. “Few clinical issues are black and white. For example, dealing with hypertension in theory can be relatively straightforward, and treatment guidelines are important, but when you have an elderly patient who has dementia and can’t always remember to take their meds it becomes more complex. These are the sort of practical issues that can be teased out at small group meetings.”

Funding for additional tutors

At the end of her three-year tenure as CME director, Finola hopes that the scheme will have secured the necessary funding for additional tutors. 

“I would like to ensure that CME is accessible to all; that you can graduate as a GP and join a scheme and get the support and education that you need.

“Most of all I would like group sizes to be reduced and a reduction in the number of groups per tutor. This is all dependent on improved resourcing. It has always been felt that the ideal attendance number at a small group meeting is eight to 12 but some of the urban meetings are averaging 12-14 and more. I feel the smaller group size is more conducive to more open discussion and better learning.”

In spite of the obvious convenience of e-learning, webinars etc, small group learning is still the most popular way for GPs in Ireland to meet their CPD requirements. Finola believes CME has remained popular because it provides education while exploring the nuances of how GPs introduce the necessary changes to the way they practise. 

“Michael Boland had a very clear vision. He believed the primary role of the group is educational rather than therapeutic, although to achieve the former it must be supportive.” CME’s supportive role has been the key to its success and Finola says she wishes to strengthen and protect this. 

“GPs are still turning up in great numbers on a winter’s night because they feel they get real value from the small group system. It really is a unique and enjoyable form or learning.”